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Based on review of medical records, Medical Staff Rules and Regulations, policies and procedures and staff interview it was determined that the facility failed to ensure that an appropriate medical screening examination (MSE) and transfer were performed for one (P#1) of of 20 sampled patients. Specifically, the facility failed to provide an appropriate MSE, including psychiatric evaluation for P#1. In addition, the facility failed to provide appropriate transfer, by discharging P#1 who had ongoing suicidal ideations without appropriate safety precautions in place.

Findings included:

Cross refer to 2406 as it relates to the facility's failure to conduct an appropriate medical screening examination.

Cross refer to 2409 as it relates to the facility's failure to effect an appropriate transfer.

Based on medical record review, policies and procedures and staff interviews, it was determined that the facility failed to provide an appropriate, ongoing medical screening examination to determine whether an emergency medical condition (EMC) existed, including psychiatric examination for one (P#1) of 20 sampled patients. Specifically, P#1 presented to the facility's Emergency Department with complaint of a 'psychiatric problem' on 8/5/23. P#1 endorsed suicidal ideations with a plan during the triage assessment. P#1 was not assessed or seen by a psychiatrist and an appropriate psychiatric evaluation was not done as there was no assessment of judgement, insight or thought process during the ED stay. P#1 was discharged into the care of a family member on 8/8/23 at 10:30 a.m. and found deceased by hanging on 8/9/23.

Findings included:

A review of Patient (P)#1 medical record revealed she was admitted to the ED (Emergency Department) on 8/5/23 at 1:50 a.m. She was ambulatory on arrival to the ED and was accompanied by police officers. Police Officers found P#1 with two propane tanks in her car, "to blow self-up". P#1 reported "I was just going to make myself pass out" per documentation in P#1 medical record. P#1 denied loss of consciousness and reported "I have been to four different facilities in this month".

On 8/5/23 at 2:00 a.m. Medical Doctor (MD) CC performed a medical examination on P#1. A review of systems revealed psychiatric symptoms were depression and suicidal. Additional review of systems information was that all other symptoms were reviewed and otherwise negative. MD CC further documented from his medical examination that P#1 was cooperative, mood and affect was depressed, abnormal/psychotic thoughts: suicidal, not homicidal, not delusional, no hallucinations.

On 8/5/23 at 2:07 a.m. a 1013 Form (Certificate Authorizing Transport To Emergency Receiving Facility & Report of Transportation (Mental Health) was signed by MD CC.

On 8/6/23 at 9:00 a.m. P#1 was examined by Nurse Practitioner (NP) HH. NP HH documented P#1 was a 1013 for safety and was medically cleared, waiting for mental health bed placement in another facility.

On 8/7/23 at 9:09 a.m. P#1 was evaluated by NP II. NP II documented P#1 was currently waiting for acceptance to mental health facility.

On 8/7/23 at 3:38 p.m. MD GG saw P#1 and performed a face-to-face evaluation. He documented P#1 was not hearing any voices, did not want help with methamphetamine abuse at that time. MD GG further documented that P#1 was alert and oriented and was without any suicidal or homicidal ideation. MD GG documented to continue with 1013 observation until able to transfer to mental health for psychiatric evaluation/treatment.

On 8/8/23 at 3:45 a.m. MD FF documented that P#1 became agitated, wanted to be discharge so she can go to a facility in Florida that supposedly was set up for her. Unfortunately, she could not find a family member that could take the responsibility. MD FF further documented he did not feel that P#1 was safe being discharged on her own so he renewed her 1013 until she could be placed at a psychiatric facility for evaluation. P#1's care was transferred to MD EE on 8/8/23 at 7:00 a.m.

On 8/8/23 at 7:00 a.m. MD EE documented an addendum that P#1 was seen earlier for suicide ideation after she was using drugs. P#1 was anxious to go home. P#1 denied adamantly being suicidal or homicidal. MD EE further documented P#1's father was here and spoke with him to arrange that inpatient hospitalization seemed reliable. P#1 would be discharged with substance abuse and depression. A further review of MD EE's documentation revealed P#1 denied any suicidal or homicidal ideation and that P#1's father was at the bedside and assumed care to The Way at Clearwater. P#1 was medically clear for discharge per MD EE progress notes.

On 8/8/23 at 10:20 a.m. P#1 was discharged to her father.

A review of the facility's policy titled" Medical Screening Examination and Stabilization Policy" no policy number, last reviewed 11/1/21, revealed that it is the facility's policy that when an individual comes to the dedicated emergency department (DED) and a request is made on his or her behalf for an examination or treatment for a medical condition, or a prudent layperson observer would believe that the individual presented with an emergency medical condition (EMC), an appropriate medical screening examination (MSE), within the capabilities of the hospitals DED (including ancillary services routinely available and the availability of on call physicians), shall be performed by an individual qualified to perform such examination to determine whether an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC.

If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capability and capability of the facility, or an appropriate transfer as required by EMTALA. Such stabilization treatment shall be applied in a non-discriminatory manner (a different level of care because if diagnosis, financial, status, race, color, national origin, or handicap).

An interview was conducted on 9/4/24 at 1:10 p.m. in classroom one via telephone with Medical Director (MD) JJ. He revealed the facility is a medical clearance facility. A medical examination and laboratory reviews are conducted to see if there is any medical reason why person may be having a psychiatric crisis. If the person was cleared medically then it would be determined whether or not the person needed a 1013 or a 2013 order. When this is determined the facility would then decide as to where person would be sent to. It was not common but not unusual to rescind on a 1013 while person was in the ED for an extended period of time. Whatever was going on at the time of admission may have resolved or changed during an extended stay in the ED. The patient could be discharged to family if they were involved.

An interview was conducted on 9/4/24 at 4:14 p.m. via telephone in classroom one with MD FF. He revealed he did not remember P#1. He further revealed it was not a common practice for a 1013 to be rescinded. It all depended on the patient's situation regarding family support and the patient would have to be stable enough not to harm him/herself.

An interview was conducted on 9/6/24 at 3:56 p.m. via telephone with MD CC. MD CC revealed the facility is a tricky facility because it does not have any psychiatry backup. He further revealed in other facilities he had worked in they would have a crisis coordinator who would come in and evaluate the patient. MD CC stated they do try to coordinator with other facilities to try to place the 1013 patients.

Based on review of medical records, policies and procedures and interviews with staff it was determined that the facility failed to provide one (P#1) of 20 sampled patients with an appropriate transfer. Specifically, P#1, a psychiatric patient with a history of prior inpatient hospitalizations and suicide attempts was seen in the facility's Emergency Department (ED) under an involuntary hold for suicidal ideations. Attempts to transfer P#1 to an inpatient psychiatric facility were unsuccessful. After three days in the ED, P#1 was discharged in the care of a family member who reportedly had secured P#1 a bed in an inpatient facility out of state. Neither facility staff nor providers communicated with the reported intended facility.

Findings included:

A review of Patient (P)#1 medical record revealed she was admitted to the ED (Emergency Department) on 8/5/23 at 1:50 a.m. She was ambulatory on arrival to the ED and was accompanied by police officers. Police Officers found P#1 with two propane tanks in her car, "to blow self-up". P#1 reported "I was just going to make myself pass out" per documentation in P#1 medical record.

On 8/5/23 at 2:07 a.m. a 1013 Form (Certificate Authorizing Transport To Emergency Receiving Facility & Report of Transportation (Mental Health) was signed by MD CC.

On 8/6/23 at 9:00 a.m. P#1 was examined by Nurse Practitioner (NP) HH. NP HH documented P#1 was a 1013 for safety and was medically cleared, waiting for mental health bed placement in another facility.

On 8/7/23 at 3:38 p.m. MD GG saw P#1 and performed a face-to-face evaluation. MD GG documented to continue with 1013 observation until able to transfer to mental health for psychiatric evaluation/treatment.

On 8/8/23 at 3:45 a.m. MD FF documented P#1 becoming agitated, wants to be discharge so she can go to some facility in Florida that supposedly was set up for her. Unfortunately, she could not find a family member that can take the responsibility there. MD FF further documented he did not feel that she is safe being discharged on her own so he renewed her 1013 until she could be placed at a psychiatric facility for evaluation. P#1's care was transferred to MD EE on 8/8/23 at 7:00 a.m.

On 8/8/23 at 7:00 a.m. MD EE documented an addendum that P#1 was seen earlier for suicide ideation after she was using drugs. P#1 was anxious to go home. P#1 denied adamantly being suicidal homicidal P#1's father was here and spoke with him to arrange that inpatient hospitalization seemed reliable. P#1 would be discharged with substance abuse and depression. A further review of MD EE's documentation revealed P#1 denied any suicidal or homicidal ideation and that P#1's father was at the bedside and assumed care to The Way at Clearwater. P#1 was medically clear for discharge per MD EE progress notes

On 8/8/23 at 10:20 a.m. P#1 was discharged to her father.

A review of the facility's policies and procedures titled "EMTALA-Transfer Policy, date approved 4/20/12, date reviewed 10/20/21, revealed the policy reflected the guidance under the Emergency Medical Treatment and Labor Act (EMTALA) and associated State Laws only. Any transfer of an individual with an emergency medical condition (EMC) would be initiated either by a written request for transfer from the individual legally responsible person acting on the individual's behalf or by a physician order with the appropriate physician certification as required under EMTALA. EMTALA obligations regarding the appropriate transfer of an individual determined to have an emergency medical condition (EMC) would be applicable in any dedicated emergency care center of the Health System whether located on or off the hospital campus and in all other departments of the hospital located on Health System property. The policy further revealed Transfer of individual Who are Medically Stable. EMTALA Would Not Apply. An individual who had been medically stabilized could be transferred upon request or pursuant to pre-arranged transfer/treatment plan of state, county or other entities if the individual agreed to the transfer and all of the following conditions are met: For transferring an individual with a psychiatric condition, the individual would be considered stabilized when he/she is protected and prevented from injuring himself/herself or others.
Consent. The individual must consent to the transfer; and Conditions of Participation (CoP). The applicable Medicare Conditions of Participation (CoP) applied to the transfer of a medically stable individual.

An interview was conducted on 9/4/24 at 1:10 p.m. in classroom one via telephone with Medical Director (MD) JJ. He revealed the facility is a medical clearance facility. A medical examination and laboratory reviews are conducted to see if there is any medical reason why person may be having a psychiatric crisis. If the person was cleared medically then it would be determined whether or not the person needed a 1013 or a 2013 order. When this is determined the facility would then decide as to where person would be sent to. It was not common but not unusual to rescind on a 1013 while person was in the ED for an extended period of time. Whatever was going on at the time of admission may have resolved or changed during an extended stay in the ED. The patient could be discharged to family is they were involved. The patient may sign a "No Harm Statement" releasing the facility and physicians from any liability.

An interview was conducted on 9/6/24 at 3:56 p.m. via telephone with MD CC. MD CC revealed the facility is a tricky facility because it does not have any psychiatry backup. He further revealed in other facilities he had worked in they would have a crisis coordinator who would come in and evaluate the patient. MD CC stated they do try to coordinator with other facilities to try to place the 1013 patients.